Do you know how to make medical record corrections and amendments? CMS refers to information that occurs following the visit documentation as “amendments”. Did you ever finish a note only to discover several days later that you forgot to add something? Whether on a paper and pencil system or electronic medical record system (EMR) there is specific guidance on how corrections, amendments and addendums are to be entered and documented. This week the Joint DME Task Force notified DME providers of their collective concerns as a result of recent audits of the corrections and amendments that are not properly documented or provided during medical review and audit. This information provided by the Task Force is applicable to all providers, not just those enrolled as DMEPOS suppliers.
Pointers on How to Make Medical Record Corrections and Amendments
The Medicare Program Integrity Manual (Internet-only Manual 100-08), Chapter 3, Section 126.96.36.199 provides the following guidance on amendments, corrections and delayed entries:
Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:
- Clearly and permanently identify any amendment, correction or delayed entry as such; and,
- Clearly indicate the date and author of any amendment, correction or delayed entry; and,
- Not delete but instead clearly identify all original content.
As noted by the DME Task Force, these record keeping principles apply to all medical records, whether electronic or handwritten; however, the Program Integrity Manual also specifically addresses amendments, corrections and delayed entries in EHRs with the following instructions:
Medical record keeping within an EHR deserves special considerations; however, the principles above remain fundamental and necessary for document submission to MACs, CERT, Recovery Auditors, and ZPICs. Records sourced from electronic systems containing amendments, corrections or delayed entries must:
- Distinctly identify any amendment, correction or delayed entry; and,
- Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.
We are also cautioned by the DME task force that “manner in which an EHR system notates amendments and corrections can differ by software vendor”. And as a result a provider may not be aware of the outputting both the original and amended documentation note when send the claim for medical review. Often reviewers receive only the “amended record with no indication of what was amended or corrected, when the change occurred or by whom the change was made.” As such the failure to provide a complete record including changes inconsistent with the CMS manual instructions may result in claim denial.
The final guidance offered by the Task Force on how to make medical record corrections and amendments is that “suppliers must ensure that if providing a medical record that has been amended or corrected, that the original medical record note is also provided to the requesting entity.”
Do you ever correct your therapy notes? Are you correcting them according to the three steps noted above?
Source: Joint DME MAC Publication